Collection Information Statement for Businesses

Form 433b: Collection Information Statement for Businesses

Use Tax Form 433b: Collection Information Statement for Businesses as a stand alone tax form calculator to quickly calculate specific amounts for your 2024 tax return. Alternatively you can use one of our Combined Federal and State Tax Estimator to quickly calculate your salary, tax and take home pay.

< td colspan="7">Does the business use a Payroll Service Provider or Reporting Agent (If yes, answer the following)

Collection Information Statement for Businesses

Note: Complete all entry spaces with the current data available or "N/A" (not applicable). Failure to complete all entry spaces may result in rejection of your request or significant delay in account resolution. Include attachments if additional space is needed to respond completely to any question.
Section 1: Business Information
1a	Business Name				2a	Employer Identification No. (EIN)
1b	Business Street Address Mailing Address City   State   ZIP				2b	Type of entity (Check appropriate box below) Partnership   Corporation   Other Limited Liability Company (LLC) classified as a corporation Other LLC - Include number of members
1c	County				2c	Date Incorporated/Established mmddyyyy
1d	Business Telephone				3a	Number of Employees
1e	Type of Business				3b	Monthly Gross Payroll
					3c	Frequency of Tax Deposits
1f	Business Website (web address)				3d	Is the business enrolled in Electronic Federal Tax Payment System (EFTPS) Yes   No
4	Does the business engage in e-Commerce (Internet sales) If yes, complete 5a and 5b.						Yes   No
PAYMENT PROCESSOR (e.g., PayPal, Authorize.net, Google Checkout, etc.) Name and Address (Street, City, State, ZIP code)						Payment Processor Account Number
5a
5b
CREDIT CARDS ACCEPTED BY THE BUSINESS
Type of Credit Card (e.g., Visa, Mastercard, etc.)			Merchant Account Number			Issuing Bank Name and Address (Street, City, State, ZIP code)
6a						Phone
6b						Phone
6c						Phone
Section 2: Business Personnel and Contacts
PARTNERS, OFFICERS, LLC MEMBERS, MAJOR SHAREHOLDERS, ETC.
7a	Full Name				Social Security Number
	Title				Home Telephone
	Home Address				Work/Cell Phone
	City   State   ZIP				Ownership Percentage & Shares or Interest
	Responsible for Depositing Payroll Taxes Yes   No				Annual Salary/Draw
7b	Full Name				Social Security Number
	Title				Home Telephone
	Home Address				Work/Cell Phone
	City   State   ZIP				Ownership Percentage & Shares or Interest
	Responsible for Depositing Payroll Taxes Yes   No				Annual Salary/Draw
7c	Full Name				Social Security Number
	Title				Home Telephone
	Home Address				Work/Cell Phone
	City   State   ZIP				Ownership Percentage & Shares or Interest
	Responsible for Depositing Payroll Taxes Yes   No				Annual Salary/Draw
7d	Full Name				Social Security Number
	Title				Home Telephone
	Home Address				Work/Cell Phone
	City   State   ZIP				Ownership Percentage & Shares or Interest
	Responsible for Depositing Payroll Taxes Yes   No				Annual Salary/Draw
Section 3: Other Financial Information (Attach copies of all applicable documents)
8	Yes   No
Name and Address (Street, City, State, ZIP code)						Effective dates (mmddyyyy)
9	Is the business a party to a lawsuit (If yes, answer the following)							Yes   No
Plaintiff   Defendant		Location of Filing	Represented by				Docket/Case No.
Amount of Suit $			Possible Completion Date (mmddyyyy)				Subject of Suit
10	Has the business ever filed bankruptcy (If yes, answer the following)							Yes   No
Date Filed (mmddyyyy)		Date Dismissed (mmddyyyy)		Date Discharged (mmddyyyy)			Petition No.	District of Filing
11	Do any related parties (e.g., officers, partners, employees) have outstanding amounts owed to the business (If yes, answer the following)							Yes   No
Name and Address (Street, City, State, ZIP code)		Date of Loan		Current Balance As of mmddyyyy $			Payment Date	Payment Amount $
12	Have any assets been transferred, in the last 10 years, from this business for less than full value (If yes, answer the following)							Yes   No
List Asset		Value at Time of Transfer $		Date Transferred (mmddyyyy)			To Whom or Where Transferred
13	Does this business have other business affiliations (e.g., subsidiary or parent companies) (If yes, answer the following)							Yes   No
Related Business Name and Address (Street, City, State, ZIP code)					Related Business EIN:
14	Any increase/decrease in income anticipated (If yes, answer the following)							Yes   No
Explain (Use attachment if needed)			How much will it increase/decrease $				When will it increase/decrease
15	Is the business a Federal Government Contractor (Include Federal Government contracts in #18, Accounts/Notes Receivable)							Yes   No
Section 4: Business Asset and Liability Information
16a	CASH ON HAND Include cash that is not in the bank				Total Cash on Hand		$
16b	Is there a safe on the business premises   Yes   No				Contents
BUSINESS BANK ACOUNTS Include online and mobile accounts (e.g., PayPal), money market accounts, savings accounts, checking accounts and stored value cards (e.g., payroll cards, government benefit cards, etc.) List safe deposit boxes including location, box number and value of contents. Attach list of contents.
Type of Account		Full Name and Address (Street, City, State, ZIP code) of Bank, Savings & Loan, Credit Union or Financial Institution			Account Number		Account Balance As of mmddyyyy
17a							$
17b							$
17c							$
17d	Total Cash in Banks (Add lines 17a through 17c and amounts from any attachments)						$
ACCOUNTS/NOTES RECEIVABLE Include e-payment accounts receivable and factoring companies, and any bartering or online auction accounts. (List all contracts separately including contracts awarded, but not started). Include Federal, state and local government grants and contracts.
Name & Address (Street, City, State, ZIP code)		Status (e.g., age, factored, other)	Date Due (mmddyyy)		Invoice Number or Government Grant or Contract Number		Amount Due
18a	Contact Name Phone						$
18b	Contact Name Phone						$
18c	Contact Name Phone						$
18d	Contact Name Phone						$
18e	Contact Name Phone						$
18f	Outstanding Balance (Add lines 18a through 18e and amounts from any attachments)						$
INVESTMENTS List all investment assets below. Include stocks, bonds, mutual funds, stock options, certificates of deposit and commodities (e.g., gold, silver, copper, etc.).
Name of Company & Address (Street, City, State, ZIP code)		Used as collateral on loan		Current Value		Loan Balance		Equity Value Minus Loan
19a	Phone	Yes   No		$		$		$
19b	Phone	Yes   No		$		$		$
19c	Total Investments (Add lines 19a, 19b, and amounts from any attachments)						$
AVAILABLE CREDIT Include all lines of credit and credit cards.
Full Name & Address (Street, City, State, ZIP code)			Credit Limit		Amount Owed As of mmddyyyy		Available Credit As of mmddyyyy
20a	Account No.		$		$		$
20b	Account No.		$		$		$
20c	Total Credit Available (Add lines 20a, 20b, and amounts from any attachments)						$
REAL PROPERTY Include all real property and land contracts the business owns/leases/rents.
		Purchase/ Lease Date (mmddyyyy)	Current Fair Market Value (FMV)	Current Loan Balance	Amount of Monthly Payment		Date of Final Payment (mmddyyyy)	Equity FMV Minus Loan
21a	Property Description		$	$	$			$
Location (Street, City, State, ZIP code) and County					Lender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and Phone Phone
21b	Property Description		$	$	$			$
Location (Street, City, State, ZIP code) and County					Lender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and Phone Phone
21c	Property Description		$	$	$			$
Location (Street, City, State, ZIP code) and County					Lender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and Phone Phone
21d	Property Description		$	$	$			$
Location (Street, City, State, ZIP code) and County					Lender/Lessor/Landlord Name, Address, (Street, City, State, ZIP code) and Phone Phone
21e	Total Equity (Add lines 21a through 21d and amounts from any attachments)						$
VEHICLES, LEASED AND PURCHASED Include boats, RVs, motorcycles, all-terrain and off-road vehicles, trailers, mobile homes, etc.
		Purchase/ Lease Date (mmddyyyy)	Current Fair Market Value (FMV)	Current Loan Balance	Amount of Monthly Payment		Date of Final Payment (mmddyyyy)	Equity FMV Minus Loan
22a   Year	Make/Model		$	$	$			$
Mileage	License/Tag Number	Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone Phone
Vehicle Identification Number (VIN)
22b   Year	Make/Model		$	$	$			$
Mileage	License/Tag Number	Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone Phone
Vehicle Identification Number (VIN)
22c   Year	Make/Model		$	$	$			$
Mileage	License/Tag Number	Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone Phone
Vehicle Identification Number (VIN)
22d   Year	Make/Model		$	$	$			$
Mileage	License/Tag Number	Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone Phone
Vehicle Identification Number (VIN)
22e	Total Equity (Add lines 22a through 22d and amounts from any attachments)						$
BUSINESS EQUIPMENT AND INTANGIBLE ASSETS Include all machinery, equipment, merchandise inventory, and other assets in 23a through 23d. List intangible assets in 23e through 23g (licenses, patents, logos, domain names, trademarks, copyrights, software, mining claims, goodwill and trade secrets.)
		Purchase/ Lease Date (mmddyyyy)	Current Fair Market Value (FMV)	Current Loan Balance	Amount of Monthly Payment		Date of Final Payment (mmddyyyy)	Equity FMV Minus Loan
23a	Asset Description		$	$	$			$
Location of asset (Street, City, State, ZIP code) and County					Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone Phone
23b	Asset Description		$	$	$			$
Location of asset (Street, City, State, ZIP code) and County					Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone Phone
23c	Asset Description		$	$	$			$
Location of asset (Street, City, State, ZIP code) and County					Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone Phone
23d	Asset Description		$	$	$			$
Location of asset (Street, City, State, ZIP code) and County					Lender/Lessor Name, Address, (Street, City, State, ZIP code) and Phone Phone
23e	Intangible Asset Description						$
23f	Intangible Asset Description						$
23g	Intangible Asset Description						$
23h	Total Equity (Add lines 23a through 23g and amounts from any attachments)						$
BUSINESS LIABILITIES Include notes and judgements not listed previously on this form.
Business Liabilities		Secured/ Unsecured	Date Pledged (mmddyyyy)	Balance Owed	Date of Final Payment (mmddyyyy)		Payment Amount
24a	Description:	Secured Unsecured		$			$
Name Street Address City/State/ZIP code   Phone
24b	Description:	Secured Unsecured		$			$
Name Street Address City/State/ZIP code   Phone
24c	Total Payments (Add lines 24a and 24b and amounts from any attachments)						$
Section 5: Monthly Income/Expenses Statement for Business
Accounting Method Used: Cash   Accrual
Use the prior 3, 6, 9 or 12 month period to determine your typical business income and expenses.
Income and Expenses during the period (mmddyyyy)   to (mmddyyyy)
Provide a breakdown below of your average monthly income and expenses, based on the period of time used above.
Total Monthly Business Income					Total Monthly Business Expenses
	Income Source		Gross Monthly			Expense items		Actual Monthly
25	Gross Receipts from Sales/Services		$		36	Materials Purchased		$
26	Gross Rental Income		$		37	Inventory Purchased		$
27	Interest Income		$		38	Gross Wages & Salaries		$
28	Dividends		$		39	Rent		$
29	Cash Receipts (Not included in lines 25-28)		$		40	Supplies		$
	Other Income (Specify below)				41	Utilities/Telephone		$
30			$		42	Vehicle Gasoline/Oil		$
31			$		43	Repairs & Maintenance		$
32			$		44	Insurance		$
33			$		45	Current Taxes		$
34			$		46	Other Expenses (Specify)		$
35	Total Income (Add lines 25 through 34)		$		47	IRS Use Only-Allowable Installment Payments		$
					48	Total Expenses (Add lines 36 through 47)		$
					49	Net Income (Line 35 minus Line 48)		$
1   Materials Purchased: Materials are items directly related to the production of a product or service. 2   Inventory Purchased: Goods bought for resale. 3   Supplies: Supplies are items used to conduct business and are consumed or used up within one year. This could be the cost of books, office supplies, professional equipment, etc. 4   Utilities/Telephone: Utilities include gas, electricity, water, oil, other fuels, trash collection, telephone, cell phone and business internet. 5   Current Taxes: Real estate, state, and local income tax, excise, franchise, occupational, personal property, sales and the employer's portion of employment taxes.

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